This chapter: o Motivates the clinical use of robotic tele-echography o Introduces the TER system o Describes technical and clinical evaluations performed with TER

OBJECTIVE:The TER system is a robot-based tele-echography system allowing remote ultrasound examination. The specialist moves a mock-up of the ultrasound probe at the master site, and the robot reproduces the movements of the real probe, which sends back ultrasound images and force feedback. This tool could be used to perform ultrasound examinations in small health care centers or from isolated sites. The objective of this study was to prove, under real conditions, the feasibility and reliability of the TER system in detecting abdominal aortic and iliac aneurysms.METHODS:Fifty-eight patients were included in 2 centers in Brest and Grenoble, France. The remote examination was compared with the reference standard, the bedside examination, for aorta and iliac artery diameter measurement, detection and description of aneurysms, detection of atheromatosis, the duration of the examination, and acceptability.RESULTS:All aneurysms (8) were detected by both techniques as intramural thrombosis and extension to the iliac arteries. The interobserver correlation coefficient was 0.982 (P < .0001) for aortic diameters. The rate of concordance between 2 operators in evaluating atheromatosis was 84% +/- 11% (95% confidence interval).CONCLUSIONS:Our study on 58 patients suggests that the TER system could be a reliable, acceptable, and effective robot-based system for performing remote abdominal aortic ultrasound examinations. Research is continuing to improve the equipment for general abdominal use.

Grenoble was one of the first places worldwide where a robot was used in clinical routine. In 1989, the first robot-assisted procedure on a patient took place in the neurosurgery department of the Grenoble University Hospital. An industrial robot modified to satisfy to the clinical constraints was used as a positioning device for guiding minimally invasively the surgical tool to a planned target. Based on that experience and on our knowledge of the clinical domain, we progressively re-directed our activity towards the design of specific robotic devices answering important issues among which safety, interactivity and clinical suitability. In this paper, we describe in more details our view of what surgical robotics is and should be and we illustrate our approach by the description and discussion of research in progress at TIMC: the PADyC arm, a passive device constraining the surgeon s motions in function of a pre-planned surgical protocol - the TER system a non rigid and portable robot for tele-echography - and LER a portable endoscope holder. We will discuss the specificities of medical robotics. Finally, we will draw the perspectives that we foresee for this domain.

Objective: This report describes the design, development, and testing of a novel compact surgical assistant robot to control the orientation and insertion depth of a laparoscopic endoscope during minimally invasive abdominal surgery. In contrast to typical endoscope manipulators, the described robot is particularly compact and lightweight, is simple to set up and use, occupies no floor or operating table space, and does not limit access to the patient in any way.Materials and Methods: The sterilizable endoscope manipulator is sufficiently small and lightweight at 625 g and 110 mm in diameter that it can be placed directly on the abdomen of the patient without interfering with other handheld instruments during minimally invasive surgery. It consists of an annular base, a clamp to hold an endoscope trocar, and two joints which enable azimuth rotation and inclination of the endoscope about a pivot point at the incision. The endoscope insertion depth is controlled by a cable winding acting against a compression spring on the endoscope shaft. Voice recognition and miniature keypad user command interfaces are provided, and the manipulator motors are backdriveable for manual repositioning.Results: Endoscope camera trajectory-following accuracy and response-time results were measured using an optical localizer. Experimental results are given comparing the current prototype with the previous cable-driven prototype. The endoscope manipulator and its user interface were tested and evaluated by several surgeons during a series of minimally invasive surgical training procedures on cadavers and animals.Conclusions: The endoscope manipulator described has been shown to be a viable, practical device with performance and functionality equivalent to those of commercially available models, yet with greatly reduced size, weight, and cost.

Démontrer sur quelques exemples les potentialités des Gestes Médico-Chirurgicaux Assistés par Ordinateur. Quatre produits ou prototypes seront démontrés en permanence sur le stand I4 « GMCAO ». Les visiteurs pourront s’initier à une pratique innovante d’interventions médicales ou chirurgicales. Station SURGETICS® de PRAXIM-Medivision : station de navigation chirurgicale stratégies planifiée et réalisée sont comparées (à partir de données pré-opératoires de type tomodensitométrie ou IRM, ou à partir de données géométriques ou dynamiques acquises pendant l’intervention). Par exemple : chirurgie orthopédique, chirurgie de la base du crâne par voie ORL, chirurgie dentaire, ponction de rein sous guidage échographique. RPL (Robot de Ponction Léger sous scanner ou sous IRM). Ce prototype a pour objectif de transformer tout scanner ou IRM en scanner ou IRM interventionnels. Son architecture très particulière (parallèle et séquentielle) lui permet de suivre naturellement les mouvements physiologiques du patient (respiration par exemple). TER (Télé-Echographie Robotisée). Ce robot léger et intrinsèquement compliant permet à un opérateur distant de prendre complètement le contrôle d’un examen échographique. REL (Robot Endoscopique Léger). Ce robot permet de contrôler l’orientation et le zoom d’une caméra endoscopique. Il offre une « troisième main » au chirurgien. Les convergences entre GMCAO et radiologie interventionnelle sont multiples et fructueuses.

Démontrer sur quelques exemples les potentialités des Gestes Médico-Chirurgicaux Assistés par Ordinateur (GMCAO). A partir de données pré-opératoires de type tomodensitométrie ou IRM, ou à partir de données géométriques ou dynamiques acquises pendant l’intervention sur une station SURGETICS® de PRAXIM-Medivision (station de navigation chirurgicale), des stratégies planifiées et réalisées sont comparées. Par exemple : chirurgie orthopédique, chirurgie de la base du crâne par voie ORL, chirurgie dentaire, ponction de rein sous guidage échographique. RPL (Robot de Ponction Léger sous scanner ou sous IRM). Ce prototype a pour objectif de transformer tout scanner ou IRM en scanner ou IRM interventionnels. Son architecture très particulière (parallèle et séquentielle) lui permet de suivre naturellement les mouvements physiologiques du patient (respiration par exemple). TER (Télé-Echographie Robotisée). Ce robot léger et intrinsèquement compilant permet à un opérateur distant de prendre complètement le contrôle d’un examen échographique. REL (Robot Endoscopique Léger). Ce robot permet de contrôler l’orientation et le zoom d’une caméra endoscopique. Il offre une « troisième main » au chirurgien. Quatre produits ou prototypes seront démontrés en permanence sur le stand 14 « GMCAO ». Les visiteurs pourront s’initier à une pratique innovante d’interventions médicales ou chirurgicales. Les convergences entre GMCAO et radiologie interventionnelle sont multiples et fructueuses.

This paper describes the development of a compact laparoscopic endoscope manipulator and its command interface for use as a surgical assistant during minimally invasive surgery. The defining feature of the endoscope manipulator is that it is sufficiently small and lightweight to be fixed directly on the abdomen of the patient. The mechanism of the manipulator controls the orientation of the endoscope and its insertion depth. It is actuated by cables inside flexible sleeves connected to a separate enclosure containing analogue controllers, servomotors and rack-and-pinion drives. Compared with floor-standing endoscope manipulators, the described device is easier to set up, cheaper, simpler and allows unrestricted access to the abdomen from all sides of the patient. The pointing accuracy of the device is reduced by the absence of a rigid base, but the resulting compliance to patient motion is an added benefit. The current prototype has been tested on a cadaver. The design and control of the endoscope manipulator continues to evolve in response to testing results and consultation with surgeons, with light weight, small size, simplicity and ease of use as primary considerations. A novel hands-free user control interface for orientation of the endoscope manipulator using an external optical localizer to track surgical instruments is also presented.

LER is a compact surgical assistant robot for positioning of an endoscope and camera during minimally invasive surgery. In contrast to typical endoscope manipulators, LER is particularly compact and lightweight at 625 g and 110 mm in diameter so that it is simple to set up and use, occupies no floor space, and does not limit access to the patient in any way. Our current prototype is fully sterilizeable by autoclave and is ready for clinical trials. It features a full motion range of 360degrees in rotation and inclination to 10degrees from the horizontal plane and is backdriveable for manual positioning. Actuation forces are limited for safety. LER may be held in place on the abdomen by adhesive strips or sutures, or attached to the sides of the table with elastic straps or clamps. We have implemented a variety of different user command interfaces for LER, including a miniature keypad, automatic optical instrument motion tracking, and voice command recognition. Experimental trajectory following results and performance parameters are given.